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Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 17-20

Clinical appraisal of corpora cavernosa injuries (penile fracture): Retrospective review of 69 patients in Benghazi, Libya

Department of Surgery, Hawari Center for Urology and Otolaryngology Faculty of Medicine, University of Benghazi, Benghazi, Libya

Date of Submission15-Jul-2020
Date of Acceptance26-Jan-2021
Date of Web Publication10-Apr-2021

Correspondence Address:
Dr. Muftah Hamad Elkhafifi
Department of Surgery, Faculty of Medicine, University of Benghazi, Benghazi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/LJMS.LJMS_60_20

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Background and Aim: Penile fracture is a relatively rare urological emergency. The aim of this study was to review the experience with 69 consecutive cases in Benghazi, Libya. Patients and Methods: Records of 69 penile fracture cases who presented between January 1997 and December 2018 to Hawari Center for Urology, Benghazi, Libya were retrospectively reviewed. Penile fracture diagnosis was based on classic history and typical physical signs. Surgical exploration was performed for all patients under spinal anesthesia. Results: The most common mechanism of penile fracture was self-inflicted forceful bending (manipulation) of erected penis which account for 39 (56.5%) patients, followed by vigorous sexual intercourse in 19 (27.5%) patients, masturbation in five (7.2%) patients, rolling over an erect penis in bed in five (7.2%) patients, and slipping in WC in one (1.5%) patient. Clinical features at presentation include intense pain in 97%, sudden audible popping sound in 87%, rapid de tumescence in 94.2%, followed by development of swelling and ecchymosis in all patients (100%). All patients were treated surgically and no intraoperative or immediate postoperative complications were encountered. During the follow-up period, all patients had normal urinary steam and normal sexual function was experienced by 97.1% of the patients. Five patients (7.2%) had long-term complications: penile hypoesthesia (one patient), painful erection (one patient), penile curvature of <15o on erection (one patient), and mild erectile dysfunction (two patients). Most patients were discharged home on postoperative day 1. Conclusion: Penile fracture occurred mainly due to forceful sexual manipulation of erected penis, and diagnosis can be made clinically. Immediate surgical repair is the only option to avoid complications.

Keywords: Corpora cavernosa, erectile dysfunction, erection, injury, penile fracture, surgical repair

How to cite this article:
Elkhafifi MH, Y. Alaorfi WE. Clinical appraisal of corpora cavernosa injuries (penile fracture): Retrospective review of 69 patients in Benghazi, Libya. Libyan J Med Sci 2021;5:17-20

How to cite this URL:
Elkhafifi MH, Y. Alaorfi WE. Clinical appraisal of corpora cavernosa injuries (penile fracture): Retrospective review of 69 patients in Benghazi, Libya. Libyan J Med Sci [serial online] 2021 [cited 2023 Mar 30];5:17-20. Available from: https://www.ljmsonline.com/text.asp?2021/5/1/17/313524

  Introduction Top

Penile fracture is a relatively rare condition that is defined as a rupture of the tumescent corpora cavernosa as a result of blunt trauma.[1] Injuries during sexual intercourse constitute 50% of all cases; mostly with female-dominant position when penis slips out of vagina and strikes the perineum or pubic bone. Other causes include masturbation, direct blow, forced bending, turning-over in bed, unconscious nocturnal penile manipulation, hastily removing or putting on clothes with erect penis, industrial accidents, and gunshot injury.[2] Sharma et al. reported fracture of the penis in association with pharmacologically induced erection secondary to the use of sildenafil (Viagra).[3] Tunica albuginea is one of the strongest fascia in the human body. One reason for the increased risk of penile fracture is that the tunica albuginea stretches and thins significantly during erection: in the flaccid state, it is up to 2.4 mm thick; during erection, it becomes as thin as 0.25–0.5 mm.[4] Bitsch et al.[5] and De Rose et al.[4] proposed that an intracorporal pressure of 1500 mmHg or more during erection can tear the tunica albuginea.

The classic presenting features of penile fracture include a cracking/popping sound followed by sudden pain, rapid de-tumescence, and swelling, ecchymosis. The penis will often be deformed and bent in the direction of the uninjured corpora cavernosa “Eggplant deformity.”[6] If Buck's fascia is torn, the extravasation of blood and/or urine may extend to the scrotum, suprapubic region, and perineum, giving rise to the “butterfly” pattern of ecchymosis.[7] Blood at the meatus or gross hematuria was reported in cases of urethral injury.[8] Obstructive symptoms or urinary retention may be develop in the absence of urethral injury, owing to the marked hematoma and edema causing external urethral compression.[9],[10] Penile fracture is easily diagnosable due to its characteristic history and appearance. Penile fracture is a relatively rare urological emergency, and immediate repair of fracture is associated with the superior long-term results in preserving sexual and voiding functions.[1] This entity is underreported, and the patient may delay the admission due to fear or embarrassment.[11]

  Patients and Methods Top

This is a retrospective, hospital-based case series study including 69 consecutive patients who presented between January 1997 and December 2018 with the diagnosis of penile fracture to Hawari Center for Urology and Otolaryngology, Benghazi, Libya with their age ranged between 18 and 60 years. Penile fracture diagnosis was based on the classic history and typical physical signs. All patients were admitted to the hospital, and a detailed history and clinical physical examination in addition to relevant basic investigations were done. Our patients were not subjected to any imaging procedure preoperatively as the diagnosis was clear on the clinical grounds. Surgical exploration was performed for all patients under spinal anesthesia. All patients were discharged on the second postoperative day except those complicated by urethral injury where the hospital stays extend to 7 days.

Diazepam was given to all patients postoperatively to prevent spontaneous erections and patients advised to abstain from all sexual relations for 6–8 weeks and followed-up for 3–16 months for the assessment of erectile functions, penile curvature on erection, and presence of any palpable nodules.

  Results Top

Patients' age ranged from 18 to 60 years, with a mean age of 29 years. Majority of patients were belonged to the second, third, and fourth decades which are the decades of maximal sexual activity. The mean time from injury to presentation was 32 h (range: 2 h–7 days). All of the patients presented within 24 h but only one patient (1.44%) presented on the 7th day of injury. Fifty-three patients (76%) were single, and sixteen patients (23%) were married and had the trauma during sexual activity.

The etiological factors implicated in our series were self-inflicted forceful bending (manipulation) of erected penis which account for more than half of cases 39 (56.5%), vigorous sexual intercourse caused the injury in 19 (27.5%) patients, masturbation in five (7.2%) patients, rolling over an erect penis in bed in five (7.2%) patients, and slipping in WC in only one (1.5%) patient. Clinical features at presentation include intense pain in 97% (67/69), sudden audible popping sound in 87% (60/69), rapid detumescence in 94.2% (65/69), followed by the development of swelling and ecchymosis in all patients (100%). Typical “Eggplant deformity” of swelling, ecchymosis, and deviation to the opposite side were seen in 65% (45/69). Blood at external urethral meatus was seen in three (4.34%) patients but no obstructive symptoms or urinary retention in any case. No single patient was managed conservatively, and all patients were explored through distal circumcoronal incision with the following intra-operative findings: a tunical tear was found in the right corpus cavernosum in 39 (56.5%), in the left corpus in 28 (40.5%), and bilateral in 2 (2.89%). The site of tunical tear was localized to the proximal third in 41 (59.4%), middle third in 27 (39%), and distal third in only one case (1.44%). No intraoperative or immediate postoperative complications were encountered in any case. During the follow-up period which ranged from 3 to 16 months with a mean of 9.5 months, all patients had normal urinary steam and normal sexual function was experienced by 67 (97.1%) cases. Five (7.24%) patients have long-term complications, one patient (1.4%) had penile hypoesthesia, and another one (1.4%) had painful erection. Another patient (1.4%) presented with penile curvature on erection and of <15° and as patient was satisfy with his erection and intercourse no intervention was undertaken. Two patients (2.8%) had mild erectile dysfunction and one of them with bilateral fractures and both of them recovered on medical treatment with sildenafil.

  Discussion Top

Penile fracture is the most common presentation of acute penis.[12] More than 1300 cases of penile fracture appeared in the literature, the majority is reported from the Mediterranean countries.[13] El Atat et al.[14] published the largest series ever published which included 300 cases, followed by Zargooshi 172 cases,[15] Koifman et al. 150 cases,[16] Gedik et al. 107 cases,[17] Kozacıoğlu et al. 64 cases,[18] and El-Bahnasawy and Gomha who reported 60 cases.[19] Our series is considered one of the largest series to be reported in the literature. The usual cause of penile fracture is abrupt bending of the erect penis, which may occur during sexual intercourse, masturbation, rolling over in the bed, or during practice known as “tagaandan,” in which the erect penis is pushed down to achieve detumescence, resulting in a click.[15]

The age of patients with penile fracture discussed in the literature ranged from 26 to 41 years.[20] The mean age in our series is 29 years which falls within this range. Regarding the etiologies of penile fracture, those injuries from the Middle East are mostly caused by penile manipulations (bending) as with our patients, whereas the majority of the cases from the Western hemisphere are caused by vigorous intercourse, especially when the female is on top.[21] In contrast to most other published series,[14],[15],[16],[17],[18],[19] the most common etiological factors of penile fracture in our series are noncoital which is similar to the results reported in other studies[22],[23],[24],[25] and this reflect the cultural differences.

Penile fracture is easily diagnosable entity because of its typical pathognomonic features. The diagnosis of penile fracture is often straightforward and can be reliably made through a proper detailed history and physical examination. In our series, all the cases were diagnosed clinically and confirmed upon surgical exploration. Our patients were not subjected to any imaging procedures. Divers radiological methods such as cavernosgraphy,[17] ultrasonography,[26],[27] and magnetic resonance imaging (MRI)[28],[29] have been utilized to diagnose and assess penile fracture. However, an ideal radiological is lacking until now. Penile ultrasound is operator-dependent investigation and may give false results due to small albuginea disruption or presence of clots at the fracture site.[29] Caversonography carries the risk of infection, priapism, and contrast hypersensitivity in addition to its false-negative results.[30] MRI has the advantage of high soft-tissue resolution, making it the most precise imaging tool in case of penile fracture.[13] However, MRI cannot be used as a routine diagnostic study in cases of suspected penile fracture as it is costly, time-consuming, and not always available. Furthermore, although retrograde urethrography is useful to assess for suspected concomitant urethral disruption, there had several false-negative urethrograms caused by either overlying clot or perhaps not enough pressure injected.[31] Imaging studies should be reserved for cases in which the clinical history and physical examination findings conflict or for those in which no injury is apparent.[32]

The differential diagnosis of penile fracture includes vascular penile injuries (superficial dorsal vein, deep dorsal vein, and dorsal artery injuries) which are the less common causes of acute penis. Although false penile injuries (vascular injuries) are clinically similar to true penile fracture, they usually could be differentiated by the lack of the snap penile sound, absence of tunical defect, gradual detumescence, and posttraumatic new erection.[33],[34]

There is some controversy about the treatment approach for traumatic ruptures of the penis.[35] In earlier studies, conservative treatment was recommended, using pressure dressing over Foley catheter, ice packs initially and hot back later, and penoscrotal suspension associated with antibiotics and anti-inflammatory drugs,[36] as well as estrogen and diazepam for the suppression of erections.[37],[38] However, 10%–30% of patients who were treated conservatively experienced penile deformity, suboptimal erections, and coitus difficulty.[8] Several studies demonstrated that the rate of long-term complications was reduced from 30% to 4% in surgically treated patients.[29] All our patients treated surgically with satisfactory immediate and long-term outcomes.

Regarding resuming the sexual activities, it is recommended to wait for 6–8 weeks after the initial injury. Sometimes, patients may have an erection immediately postoperatively, and this may compromise the integrity of the repair, which may lead to another rupture. We found that the use of 5 mg diazepam tablet is sufficient to prevent spontaneous erections. Some authors reported that 1 mg diethylstilbestrol, daily for 1–2 weeks, or an injection of luteinizing hormone-releasing hormone agonist[4] or ketoconazole[34] found to be very effective to decrease the incidence of spontaneous erections and allow proper healing.

  Conclusion Top

Penile fracture is under-reported trauma occurred mainly to single men due to forceful sexual manipulation of erected penis. The diagnosis does not need more than the typical history and the clinically unmistakable signs. Conservative management is abandoned, and immediate surgical repair is the only option to avoid complications such as erectile and voiding dysfunctions.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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